sixfold to eightfold increase in the prevalence of coronary heart disease and peripheral vascular disease in 187 subjects examined during the recall phase of the Islington diabetes survey, associations that seemed to be independent of hypertension and diabetes.' During the three and a half years of follow up microalbuminuric subjects had an excess mortality of about 24-fold compared with those with normal urinary albumin excretion.' It is possible, therefore, that screening for microalbuminuria, rather than proteinuria, would be preferable if the test is to be used as a prognostic indicator, but in the absence of evidence of benefit from intervention this type of information may be of greater interest to life insurance companies than to the medical profession. It must be said, however, that lack of evidence of benefit has never previously constrained this government in its efforts to introduce change and innovation in the NHS. JOHN S YUDKIN RICHARD D FORREST CAROLINE JACKSON
menstruation and includes a rash among the diagnostic criteria.' He also recommends treatment with crystalloid rather than colloid solutions and describes an overall mortality of about 30/,. In these respects the toxic shock syndrome in children with burns is an important exception. The rash may appear up to a week after the acute illness,' or sometimes not at all,' and its absence is of no diagnostic value. While crystalloid solutions may form part of the general treatment of the syndrome, fresh blood or plasma may counteract the toxin by virtue of antibodies which are thought to be present in a high proportion of adults.4 In children with burns the syndrome is rare and most reports describe single cases. But one report described seven cases with a mortality of over 50%.' The toxic shock syndrome should be considered possible in children who have burns of any size and become systemically ill. It may be necessary to start treatment in the absence of some of the recognised diagnostic criteria. A J fHEYWOOD S AL-ESSA
Academic Unit of Diabetes and Endocrinology, Whittington Hospital, London N19 5NF
Royal Hospital for Sick Children, EdinbLirgh EH9 I LF
I Mant D? Fowler G. Urine analysis for glucose and protein: are the requirements of the new contract sensible? Br Med J
I Williams (R. 'I'he toxic shock syndrome. Br Med7 1990;300: 960. 14 April.) 2 Heywood AJ, Al-Essa S. Toxic shock syndrome in a child with
1990;300:1053-5. 2 World Health Organisation Study Group. Diabetes mellitus.
WHO Tech Rep Ser 1985:No 727. 3 Forrest RD, Jackson CA, Yudkin JS. The glvcohaemoglobin assay as a screening test for diabetes mellitus. 'lhe Islington diabetes survey. l)iabetic Med 1987;4:254-9. 4 Kannel WB, Stampfer Mi, Castelli WP. The prognostic significance of proteinuria: the Framingham study. Am Heart] 1984;108: 1347-52. 5 Yudkin JS, Forrest RD, Jackson CA. Microalbuminuria as a predictor of vascular disease in non-diabetic subjects: the Islington diabetes survey. Lancet 1988;ii:530-3.
Autologous transfusion SIR,-Drs Richard J E Page and Ian H Wilson describe the use of autologous transfusion by salvaging blood during surgery in developing countries.' Predeposit autologous transfusion can also be valuable. At the Kilimanjaro Christian Medical Centre in Moshi, Tanzania, autologous transfusion has helped urological surgery to continue in the face of decreasing availability of blood donors and increasing risks of transmission of malaria, hepatitis, and AIDS. In a prospective study over 12 months the use of homologous blood in prostatic surgery was reduced from 51% to under 4% in patients who received only 500 ml of autologous blood taken up to 10 days before surgery.' These examples illustrate how important it is to maintain contacts between richer and poorer nations despite the widening gap in the practice of medicine. The British Association of Urological Surgeons has recently established a group called UROLINK to encourage the provision and sharing of urological care world wide bv helping to establish links between urologists in the United Kingdom and those in the poorer two thirds of the world. There is much we can learn from each other for the benefit of all. N W HARRISON
Department of Urology, Brighton General Hospital, East Sussex BN2 3EW I Plage RJE, Wilson IH. Autologous transfusion. Br Med 7 1990;300:1139. t28 April.) 2 Eschleman JL, Young ER, Eschleman LL. Proceedings of the Asso¢}att'on j1 Surgeopts f J ast0 nfra (in press
The toxic shock syndrome SIR,-Dr Glyn R Williams emphasises both the difficulty and importance of prompt diagnosis in the toxic shock syndrome when not associated with
1464
only 2t% burn. Lancei 1990;335:867. 3 Frame JI), Evc MI), Hackett
MEJ, et al. I'he toxic shAck s\Yndrome it burned children. Burns Ittcl Thermn Inj 1985;11:
234-41.
shock syndrome, where there is a local site of tissue invasion, antibiotic killing of the organism helps resolution of tissue infection and reduces further toxin production. TFoxic shock syndrome may be accompanied by septicaemia so, in practice, parenteral antibiotics are indicated for all patients. Preference for fluid replacement by crystalloid solutions in toxic shock syndrome derives from a retrospective survey of 36 patients2 in whom changes in chest radiographs (interstitial infiltrates, pulmonary oedema, prominent vascular markings) were more common in those given colloid (8/14), especially albumen (6/8-though these patients were more ill), than those receiving crystalloid (6/18). I did not write or imply that dopamine or dobutamine were interchangeable when I wrote "inotropic support with dopamine or dobutamine may be indicated by appropriate intensive monitoring." There is a spectrum of clinical illness in those fulfilling the criteria for toxic shock syndrome, and patients with less severe toxic shock syndrome can respond readily to combinations of fluid replacement, antibiotics, and short term inotrope support. Immediate placement of such patients in intensive therapy units is not always indicated. The theme of the editorial was that prompt clinical diagnosis held the most immediate prospect of improving morbidity and mortality in toxic shock syndrome. GLYN R WILLIAMS
4 Chesney lJ. 'Toxic shock syndrome: a commentary and review of the characteristics of Staphylococcus atiretis strains. Infectiot 1 9X3;1l 18X1-XS.
DIepartment of Infectious D)iseases, Avrshirc Central Htospital, Irvine,
SIR,-We agree with Dr Glyn R Williams when he highlights the importance of toxic shock syndrome, reminding us that it is not invariably associated with menstruation and that it may be due to streptococcal as well as staphylococcal infection.' The advice on treatment could, however, have usefully been expanded. More specific guidelines for antibiotic treatment should have been given. The unsubstantiated statement that "crystalloid rather than colloid solutions should be used" is controversial. In the United Kingdom at least, most workers agree that colloid solutions are preferable for the volume resuscitation of shock.! Dr Williams provides no evidence for his assertion to the contrary. We also agree that inotropic support may be required but would point out that dopamine and dobutamine have quite different pharmacological properties and should not be considered interchangeable. The appropriate agent can be determined only by using invasive monitoring, and in shock requiring inotropes this means a thermodilution pulmonary artery flotation catheter and an arterial line.
P'H, Wand lH, e l. toxic shock syndrome: epidemiological feattures, recurrence, risk factors, and prevention. A' Jngl _7M11ed 19X0;303: 1429-35. 2 Chesttey PJ, Crass BA, l'olvak MB, et al. Foxic shock syndromc:
GRAHAM R NIMMO SIMON J MACKENZIE IAN S GRANT Intcnsive lThcrapy Unit, Westcrn General Hospital, Edinburgh EH4 2XU d 1990;300:960. I Williams GR. 'rhe toxic shock syndrome.Br.'dle t 14 April. ) 2 Shoemakcr WC, Schluchtcr M, Hopkins JA, et al. Comparison of the relative etlctiveness of colloids and crvstalloids in emergencny resuscitation. Amj Surg 1981;142:73.
AUTHOR'S REPLY,-In the toxic shock syndrome Staphylococcus aureus must be assumed to produce penicillinase, and treatment with flucloxacillin is appropriate. If sensitivity testing of the isolate shows no penicillinase production benzylpenicillin can be substituted. Alternatives for patients hypersensitive to penicillins are fusidic acid, clindamycin, and vancomycin. In toxic shock syndrome associated with menstruation antibiotics do not seem to affect initial outcome, though they reduce the risk of recurrence.' In non-menstrual toxic
Avrshire KA] 2 8SS I Da\ is JP, Chesney
management and long-term sequelac. Ann Intern Med 1982;%: 847-51.
Ibsen's play and Meissner's story SIR,-I enjoyed Dr H G Kohler's article' and would like to draw attention to another aspect of the story that remains relevant to medicine and politics to this day. The fact that An Enemy ofthe People is based on Eduard Meissner's real life story does not explain why Ibsen should have chosen to write on this theme when he did. The reason was that his earlier play Ghosts, which was published in 1881, had been considered so outrageous in Scandinavia that it was refused performance by all the leading theatres, and Ibsen himself was socially ostracised. Ghosts, which is now regarded as one of Ibsen's greatest plays, broke too many taboos to be accepted by most people at that time. Most controversially, the central theme of the play involves a young man who develops dementia secondary to syphilis, which he has inherited from his licentious father. Ibsen's purpose-to bring such issues into the public arena-had been thwarted, and he sought ways of making his position and his views about it widely known. Eduard Meissner's story provided him with an analogy that he could dramatise to that end. He hastily wrote An Enemny of the People, which was published in the following year, 1882. The central point that Ibsen wished to make was that the majority is frequently wrong and that it seeks to suppress the lone voice that speaks the truth. Hence the hero of the play, Dr Stockmann, ends with the lines, "The thing is, you see, that the strongest man in the world is the man who stands alone." Ibsen clearly saw himself as such a man. The interesting issue for medicine is that Ibsen should have chosen a medical analogy to demonstrate a social and political point. What he wanted
BMJ VOLUME 300
2 JUNE 1990
menstruation and includes a rash among the diagnostic criteria.' He also recommends treatment with crystalloid rather than colloid solutions and describes an overall mortality of about 30/,. In these respects the toxic shock syndrome in children with burns is an important exception. The rash may appear up to a week after the acute illness,' or sometimes not at all,' and its absence is of no diagnostic value. While crystalloid solutions may form part of the general treatment of the syndrome, fresh blood or plasma may counteract the toxin by virtue of antibodies which are thought to be present in a high proportion of adults.4 In children with burns the syndrome is rare and most reports describe single cases. But one report described seven cases with a mortality of over 50%.' The toxic shock syndrome should be considered possible in children who have burns of any size and become systemically ill. It may be necessary to start treatment in the absence of some of the recognised diagnostic criteria. A J fHEYWOOD S AL-ESSA
Academic Unit of Diabetes and Endocrinology, Whittington Hospital, London N19 5NF
Royal Hospital for Sick Children, EdinbLirgh EH9 I LF
I Mant D? Fowler G. Urine analysis for glucose and protein: are the requirements of the new contract sensible? Br Med J
I Williams (R. 'I'he toxic shock syndrome. Br Med7 1990;300: 960. 14 April.) 2 Heywood AJ, Al-Essa S. Toxic shock syndrome in a child with
1990;300:1053-5. 2 World Health Organisation Study Group. Diabetes mellitus.
WHO Tech Rep Ser 1985:No 727. 3 Forrest RD, Jackson CA, Yudkin JS. The glvcohaemoglobin assay as a screening test for diabetes mellitus. 'lhe Islington diabetes survey. l)iabetic Med 1987;4:254-9. 4 Kannel WB, Stampfer Mi, Castelli WP. The prognostic significance of proteinuria: the Framingham study. Am Heart] 1984;108: 1347-52. 5 Yudkin JS, Forrest RD, Jackson CA. Microalbuminuria as a predictor of vascular disease in non-diabetic subjects: the Islington diabetes survey. Lancet 1988;ii:530-3.
Autologous transfusion SIR,-Drs Richard J E Page and Ian H Wilson describe the use of autologous transfusion by salvaging blood during surgery in developing countries.' Predeposit autologous transfusion can also be valuable. At the Kilimanjaro Christian Medical Centre in Moshi, Tanzania, autologous transfusion has helped urological surgery to continue in the face of decreasing availability of blood donors and increasing risks of transmission of malaria, hepatitis, and AIDS. In a prospective study over 12 months the use of homologous blood in prostatic surgery was reduced from 51% to under 4% in patients who received only 500 ml of autologous blood taken up to 10 days before surgery.' These examples illustrate how important it is to maintain contacts between richer and poorer nations despite the widening gap in the practice of medicine. The British Association of Urological Surgeons has recently established a group called UROLINK to encourage the provision and sharing of urological care world wide bv helping to establish links between urologists in the United Kingdom and those in the poorer two thirds of the world. There is much we can learn from each other for the benefit of all. N W HARRISON
Department of Urology, Brighton General Hospital, East Sussex BN2 3EW I Plage RJE, Wilson IH. Autologous transfusion. Br Med 7 1990;300:1139. t28 April.) 2 Eschleman JL, Young ER, Eschleman LL. Proceedings of the Asso¢}att'on j1 Surgeopts f J ast0 nfra (in press
The toxic shock syndrome SIR,-Dr Glyn R Williams emphasises both the difficulty and importance of prompt diagnosis in the toxic shock syndrome when not associated with
1464
only 2t% burn. Lancei 1990;335:867. 3 Frame JI), Evc MI), Hackett
MEJ, et al. I'he toxic shAck s\Yndrome it burned children. Burns Ittcl Thermn Inj 1985;11:
234-41.
shock syndrome, where there is a local site of tissue invasion, antibiotic killing of the organism helps resolution of tissue infection and reduces further toxin production. TFoxic shock syndrome may be accompanied by septicaemia so, in practice, parenteral antibiotics are indicated for all patients. Preference for fluid replacement by crystalloid solutions in toxic shock syndrome derives from a retrospective survey of 36 patients2 in whom changes in chest radiographs (interstitial infiltrates, pulmonary oedema, prominent vascular markings) were more common in those given colloid (8/14), especially albumen (6/8-though these patients were more ill), than those receiving crystalloid (6/18). I did not write or imply that dopamine or dobutamine were interchangeable when I wrote "inotropic support with dopamine or dobutamine may be indicated by appropriate intensive monitoring." There is a spectrum of clinical illness in those fulfilling the criteria for toxic shock syndrome, and patients with less severe toxic shock syndrome can respond readily to combinations of fluid replacement, antibiotics, and short term inotrope support. Immediate placement of such patients in intensive therapy units is not always indicated. The theme of the editorial was that prompt clinical diagnosis held the most immediate prospect of improving morbidity and mortality in toxic shock syndrome. GLYN R WILLIAMS
4 Chesney lJ. 'Toxic shock syndrome: a commentary and review of the characteristics of Staphylococcus atiretis strains. Infectiot 1 9X3;1l 18X1-XS.
DIepartment of Infectious D)iseases, Avrshirc Central Htospital, Irvine,
SIR,-We agree with Dr Glyn R Williams when he highlights the importance of toxic shock syndrome, reminding us that it is not invariably associated with menstruation and that it may be due to streptococcal as well as staphylococcal infection.' The advice on treatment could, however, have usefully been expanded. More specific guidelines for antibiotic treatment should have been given. The unsubstantiated statement that "crystalloid rather than colloid solutions should be used" is controversial. In the United Kingdom at least, most workers agree that colloid solutions are preferable for the volume resuscitation of shock.! Dr Williams provides no evidence for his assertion to the contrary. We also agree that inotropic support may be required but would point out that dopamine and dobutamine have quite different pharmacological properties and should not be considered interchangeable. The appropriate agent can be determined only by using invasive monitoring, and in shock requiring inotropes this means a thermodilution pulmonary artery flotation catheter and an arterial line.
P'H, Wand lH, e l. toxic shock syndrome: epidemiological feattures, recurrence, risk factors, and prevention. A' Jngl _7M11ed 19X0;303: 1429-35. 2 Chesttey PJ, Crass BA, l'olvak MB, et al. Foxic shock syndromc:
GRAHAM R NIMMO SIMON J MACKENZIE IAN S GRANT Intcnsive lThcrapy Unit, Westcrn General Hospital, Edinburgh EH4 2XU d 1990;300:960. I Williams GR. 'rhe toxic shock syndrome.Br.'dle t 14 April. ) 2 Shoemakcr WC, Schluchtcr M, Hopkins JA, et al. Comparison of the relative etlctiveness of colloids and crvstalloids in emergencny resuscitation. Amj Surg 1981;142:73.
AUTHOR'S REPLY,-In the toxic shock syndrome Staphylococcus aureus must be assumed to produce penicillinase, and treatment with flucloxacillin is appropriate. If sensitivity testing of the isolate shows no penicillinase production benzylpenicillin can be substituted. Alternatives for patients hypersensitive to penicillins are fusidic acid, clindamycin, and vancomycin. In toxic shock syndrome associated with menstruation antibiotics do not seem to affect initial outcome, though they reduce the risk of recurrence.' In non-menstrual toxic
Avrshire KA] 2 8SS I Da\ is JP, Chesney
management and long-term sequelac. Ann Intern Med 1982;%: 847-51.
Ibsen's play and Meissner's story SIR,-I enjoyed Dr H G Kohler's article' and would like to draw attention to another aspect of the story that remains relevant to medicine and politics to this day. The fact that An Enemy ofthe People is based on Eduard Meissner's real life story does not explain why Ibsen should have chosen to write on this theme when he did. The reason was that his earlier play Ghosts, which was published in 1881, had been considered so outrageous in Scandinavia that it was refused performance by all the leading theatres, and Ibsen himself was socially ostracised. Ghosts, which is now regarded as one of Ibsen's greatest plays, broke too many taboos to be accepted by most people at that time. Most controversially, the central theme of the play involves a young man who develops dementia secondary to syphilis, which he has inherited from his licentious father. Ibsen's purpose-to bring such issues into the public arena-had been thwarted, and he sought ways of making his position and his views about it widely known. Eduard Meissner's story provided him with an analogy that he could dramatise to that end. He hastily wrote An Enemny of the People, which was published in the following year, 1882. The central point that Ibsen wished to make was that the majority is frequently wrong and that it seeks to suppress the lone voice that speaks the truth. Hence the hero of the play, Dr Stockmann, ends with the lines, "The thing is, you see, that the strongest man in the world is the man who stands alone." Ibsen clearly saw himself as such a man. The interesting issue for medicine is that Ibsen should have chosen a medical analogy to demonstrate a social and political point. What he wanted
BMJ VOLUME 300
2 JUNE 1990
